Valid Consent, Good Consent and Asymmetric Competence

In this posting I want to consider the topic of informed consent. Eric Chwang is interested in the difference between the standard needed for consent to be considered valid for normal clinical patients and the standard necessary for valid consent from research subjects (1). In this posting my sole concern is with normal patients. Chwang takes as his starting point the judgement in Canterbury v Spence, see Canterbury v Spence . This Judgement has two main strands. First the information a doctor must give a patient should be determined by the patient’s needs. The second condition places a restriction on these needs. Chwang calls the second condition the pragmatic criterion and expresses it as follows,

 “in order for consent to be valid, whether some piece of information needs to be disclosed depends on whether it might affect the patient’s (subject’s) decision whether to consent.” (2

)

The pragmatic condition seems to reflect the judgement in the Montgomery case . In this case the court held that doctors must ensure patients are fully aware of any and all risks that an individual patient, not just the risks mainstream medical practice, might consider significant. It is the consequences of accepting the information requirements of this judgement I want to explore in this posting.

The pragmatic criterion gives us some guidance as to how much information a patient should be supplied with in order to make a competent decision. Unfortunately, this guidance seems to be at odds with the idea of informed consent being based on respect for patient autonomy. Suppose a patient simply understands he is likely to die without treatment and makes a decision on solely this basis, if any additional information will not alter his decision then according to the pragmatic criterion it is unnecessary to disclose any additional information. Chwang writes,

“Suppose that the only way to save my life is by amputation. To get consent for ‘life saving treatment’, but without also mentioning that the treatment in question is amputation, would be grossly inappropriate” (3).

The question I will now discuss is what is inappropriate about obtaining consent in this way? In order to help in this discussion I will use an example provided by Steve Clarke.

“Consider the case of ‘Squeamish John’. Squeamish John cannot bear to hear the details of medical procedures; hearing these make him feel weak at the knees and dramatically diminishes his capacity to make sensible decisions. Nevertheless he does not wish to abrogate responsibility for his decision about whether or not to undergo an operation. Squeamish John wishes to participate in a restricted informed consent process in order to make his decision. He wishes to make a decision based only on the disclosure of the risks and benefits of the operation couched in cold, impersonal, statistical language. He does not wish to have any significant details of the procedure described to him.” (4).

Let us assume John gives consent in manner outlined by Clarke and he wakes minus one leg. Chwang would find this situation grossly inappropriate and according to the Montgomery judgement John’s would have given inadequate consent. I now want to consider is inappropriate or inadequate about such a decision. I will now argue what is inappropriate or inadequate about such a decision is not that it is an non autonomous one. Let it be accepted an autonomous decision is simply a decision with which the agent identifies himself and ‘cares about’; in this context I am using ‘cares about’ in the same way as it is used by Harry Frankfurt (5). If autonomy is defined in such a manner John’s decision appears to be autonomous. However, some objector might argue for any decision to be autonomous it must be made using practical reason. Even if this objection is accepted it might be argued that practical reason is closely tied to an agent’s identity and what he cares about. David Velleman for instance believes practical reason is defined by the self-understanding someone gains by playing himself (6). This understanding depends on him doing what makes sense or seems appropriate to him; he must identify with and care about such actions. However, my objector might respond further by arguing this isn’t normally how we use the term practical reason. She might argue that anyone using practical reason to make a decision should objectively weigh up all of her available options connected to this decision. Any decision made this way would satisfy the Montgomery judgement.

For the sake of argument let us assume that assume practical reason does involve some objective weighing up of all the relevant costs and benefits and that for a decision to be autonomous it must utilise practical reason as so defined. However, if we accept the above it follows that squeamish John’s cannot make an autonomous decision. In this situation John’s squeamishness means his preferred way of making his consent decision is the only possible way he can make a decision. In everyday life outside a medical context all of us sometimes delegate important decisions to experts of our choice, such as lawyers or financial advisors, without others questioning our autonomy. Are then doctors any less trustworthy than lawyers or financial advisors? It seems obvious to me that they are not. Does then the context in which informed consent takes place differ from other contexts such as the law and finance in respect of an agent’s ability to make autonomous decisions? I would suggest it does not. It follows if squeamish John is permitted to make a decision in the way he prefers it would be an autonomous decision. It further follows what Chwang finds inappropriate, or the Montgomery judgement finds inadequate, about such a decision is not that it is a non-autonomous one.

I have argued squeamish John’s proposed decision would be an autonomous one. I would suggest what Chwang finds grossly inappropriate or the Montgomery judgement inadequate about such a decision is either that it is not a good decision or a good way to make such a decision. I would argue we should not equate autonomous decisions with good decisions. Autonomous decisions are simply autonomous decision and not autonomous decisions plus another requirement. Autonomous decisions as defined above need not of necessity good decisions. None the less autonomous decisions cannot simply be made at random, by the throw of a dice for instance. Autonomous decisions must be made on the basis of some information. If it is accepted that autonomous decisions need not of necessity be good decisions then the amount of information necessary to make an autonomous decision may not always be identical with the amount of information needed to make a good decision. The above raises the question about how much information is needed to make an autonomous decision?

In order to answer the above question, we must first be clear about an agent’s purpose when making an autonomous decision. I have suggested above an autonomous decision is one which the agent ‘cares about’ and with he identifies with. This type of decision is one the agent is wholehearted about. Frankfurt argues a wholehearted decision is one with which the agent is satisfied with. He further argues satisfaction involves an absence of restlessness and any desire for change (7). It is of course true that many agents would not be satisfied with any decision they regarded as sub optimal. However, it would appear a decision need not be an optimal decision for it to be an autonomous one according to Frankfurt. All that is necessary for a decision to be autonomous is that the agent is satisfied with his decision. I accept such a position. My objector might again point out such decisions need not be rational ones and that any decision lacking rationality should not be regarded as a fully autonomous one. In reply I would question exactly what is meant by rational. I will assume in the context of giving consent rationality refers to practical rationality. If this is so I would once reiterate that some philosophers such as Velleman would regard decisions with which the agent is satisfied with as defined above or finds appropriate as practically rational. In addition, I would argue such decisions are examples of satisficing or bounded rationality. The term satisficing was introduced by Herbert Simon in 1956. Satisficing does not require an agent maximise his good. Satisficing only requires that an agent brings about an outcome that he considers good enough by some standard. My objector might now point an autonomous agent needs only to be satisfied with his decision and does not set some standard by which any option must be judged. She might then argue any such decisions are not examples of bounded rationality. In reply I would suggest satisfaction as defined above must at the very least involve some unconscious bounds and that autonomous decisions implicitly involve bounded rationality. It follows the amount of information needed for an agent to make an autonomous decision is the amount of information that would satisfy agent.

I have used the example of squeamish John to show in certain contexts, provided the only way to save someone’s life is by amputation and consent is obtained without mentioning this fact, that none the less the patient’s consent might be autonomous. Chwang believes such consent would be grossly inappropriate. Chwang’s belief seems to be based on the idea that the patient has been inadequately informed. I believe Chwang is correct in most contexts but not all. Good quality consent should be an aim of the informed consent process, see GMC guidance for consent . However, the taking of consent like medical interventions does not always occur under ideal conditions and in some contexts good quality consent may be impossible. The General Medical Council’s guidelines on consent of 1998 specifically stated that the purpose of consent was to respect patient autonomy. The current guidelines mentioned above do not explicitly base informed consent on respect for autonomy but none the less implicitly require this respect. If respect for autonomy is the sole principle on which informed consent is based then we must simply respect all autonomous decisions. My objector might point the purpose of medicine is to act beneficently towards patients. She might then use this fact to argue basing informed consent solely on respect for autonomy is simplistic. She might then suggest the purpose of informed consent should be to respect patient autonomy and enable them to make good decisions. I accept the above is the ideal which informed consent should aim for. However, in some contexts acting beneficently might clash with respecting patient autonomy. Such a clash must be resolved. I have previously suggested we cannot act truly beneficently if we fail to respect autonomy. We must give priority to respecting autonomy over acting beneficently when these values clash, see Autonomy and acting Beneficently. Accepting the above means we must in some situations accept less than ideal decisions provided these decisions are autonomous and that Chwang is mistaken to regard such decisions as inappropriate in these situations.

Lastly I want to consider whether a consequence of accepting the pragmatic criterion is accepting the concept of asymmetric competence. This concept is defined by Wilks as follows.

“If we consider a safe, routine treatment for an acute and dangerous condition (as with an appendectomy for appendicitis), it is clear that the risk in accepting the treatment is small, the benefit great, while the risk in refusing it is great and the benefit in most cases non existent. This means that one confronted with this choice would require a higher level of competence to say no than to say yes, with, indeed, a very pronounced difference between the levels” (8)

Intuitively the pragmatic criterion supports Wilks’ position. In the situation such as that envisioned by Wilks above if a patient consents a great deal of information is unlikely to alter his decision. However, were he to refuse to consent some additional information might well alter his decision. Before considering the question of asymmetric competence I will examine two related concepts. I will examine the asymmetric triggering of competence assessments and the asymmetry in information needed to give competent consent and to give a competent refusal. I will firstly argue that for pragmatic reasons there should be asymmetric triggering of competence assessments. Indeed, it seems unlikely any patient’s competence will be questioned provided his consent is sought and he consents. I would support this failure to assess competence only in situations in which there is universal agreement among health professionals that some particular treatment is in a patient’s best interests. I have argued the most important purpose of patient consent is to protect patient autonomy. The reason why competence is sometimes assessed is to ensure non-autonomous patients receive beneficent care. In the light of the above assessing a patient’s competence if he consents seems unnecessary. Provided the patient is competent his autonomous decision should be respected. However, if he was assessed as incompetent and a surrogate decision maker made a decision on his behalf then any treatment would identical with the treatment he had previously consented to. It follows no useful purpose is served by assessing a patient’s competence provided he consents to some treatment when the health benefits are clear and the risks of non-treatment great.

I will now argue there is an asymmetry in the information needed for a patient to make a competent decision when he consents and when he refuses to consent. Let it be accepted as I have argued above any autonomous decision must count as a competent decision. Let us consider squeamish John once again. John consents to treatment and is satisfied with his decision. It might be suggested the reason why John is satisfied is that he finds the decision is appropriate to him because he can justify it to himself. John can justify his decision by trusting his doctors to do what is in his best interests. The minimal amount of information John receives also satisfies the pragmatic criterion as any additional information will not alter his autonomous decision. It follows as I have argued above John can make a competent decision, even if less than an ideal one, based on the minimal information provided. Now let us consider a situation in which a patient refuses to consent and insists on only being supplied with the same minimal information available to John. In this situation, provided the patient’s condition is non-life threatening, the procedure would simply be cancelled and the patient’s competence would remain unquestioned. For example a patient who refuses to consent to a hip replacement. However, let us assume the patient’s condition is life threatening. In this situation I would argue such a patient cannot make an autonomous decision and hence is not competent to give consent. There might be one exception to the above. A suicidal patient may well have enough information to make an autonomous decision. Needless to say medicine is not in the business of helping patients commit suicide with the possible exception of those who are terminally ill. The reason why such a patient cannot make an autonomous decision is he does not have enough information to make a decision with which he can be satisfied; a decision that he can justify to himself. In addition any additional information may well alter the patient’s decision meaning the information provided in this situation does not satisfy the pragmatic criterion. It follows if we accept either that a competent decision must be autonomous one or one requiring that a competent patient has enough information to satisfy the pragmatic criterion that a patient in this situation cannot make a competent decision. It further follows there is sometimes an asymmetry in the information a patient needs to make a competent decision if he consents and the information he needs if he refuses to consent.

Let it be accepted asymmetry between the information a patient needs when he consents and refuses consent. It is then possible for a patient to be asymmetrically competent. If a patient can understand the information needed to consent but fails to understand the additional information needed to refuse consent then he is asymmetrically competent. In practice I believe this situation is unlikely to occur as it seems to me most patients will be capable of understanding the additional information.

1. Eric Chwang, 2010, A Puzzle about Consent, Journal of Applied Philosophy, 27(3).
2. Chwang, page 262.
3. Chwang, page 265.
4. Steve Clarke, 2001, Informed Consent in Medicine in Comparison with Consent with Consent in Other Areas of Human Activity, The Southern Journal of Philosophy, 39, page 177
5. Harry Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press
6. David Vellman, 2009, How We Get Along, Cambridge University Press, page 18.
7. Frankfurt, 1999, page 103.
8. Wilks, 1997, The debate over Risk-related Standards of competence, Bioethics 11(5), page 417., 2010, A Puzzle about Consent, Journal of Applied Philosophy, 27(3)..

The Decriminalisation of Drugs

Ian Gilmore, former president of the Royal College of Physicians, and one of the UK's leading doctors has argued that the government should consider the decriminalisation of drugs, see http://www.guardian.co.uk/politics/2010/aug/16/drugs-decriminalisation-doctor-ian-gilmore. He bases his argument on the fact that the ban on drug appears to have failed to either cut crime or improve health. His argument is squarely based on utilitarian principles. A similar argument is expressed by Dominic Wilkinson who suggests that when considering the decriminalisation of drugs we should ask – which is more harmful – regulated access or prohibition? See http://www.practicalethicsnews.com/practicalethics/2010/08/demedicalising-and-decriminalising-drugs.html#more . In what follows I will take a different approach as arguments such as the above use a blanket approach to harm. I will attempt to differentiate between various classes of people who are harmed by drug use.

I will take as the starting point of my argument Mill’s contention “that the only purpose for which power can be rightfully exercised over any member of a civilised community against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient” (1974, On Liberty and Other Essays. Oxford University Press (Oxfords Worlds Classics, page 69). Mill goes on to contend “each is the proper guardian of his own health, whether bodily or mental and spiritual. Mankind are greater gainers by suffering each to live as seems good to themselves, than by compelling each to live as seems good to the rest” (page 72). Mill would clearly have regarded any harm drug users do to themselves as something that should not be included in any of considerations of whether the government should decriminalise the use of drugs. I accept Mill is correct in his contention that each one of us is the proper guardian of our own health and the harm drugs do to the drug user should not be the concern of others. It follows the harm drug users do to themselves should not concern us when considering whether to decriminalise drug use. However drugs users not only harm themselves but harm others. I will now restrict my examination to the harm drug use does to others whilst ignoring any harm drug use does to the drug user. These others can be split into two classes. Firstly drug users harm people they do not personally know. I will class this harm as harm to society. Secondly they harm people they personally know, people they are in some relationship with. I will firstly consider the harm the drug users do to society and secondly the harm they do to those in a relationship with them.

Clearly drug use harms society. Muggings and robberies to finance drug taking and gangland turf wars do real harm. However the majority of this harm to society seems to occur because drugs are illegal. It follows if we were only to consider the harm done to society that we should decriminalise drug use in order to minimise this harm. Someone might argue that, besides harming society, drug users really only harm themselves. She might suggest drug users are lonely people who take drugs alone or in conjunction other drug users who they do not significantly harm due to their existing drug use. However her argument is unsound because such idealised drug users seldom exist in practice. Most drugs users live in some sort of relationship with others and one only has to consider wrecked relationships and blighted childhoods in order to see the harm drug use inflicts on others. It follows even if we accept Mill’s contention that “the only purpose for which power can be rightfully exercised over any member of a civilised community against his will, is to prevent harm to others” that in our considerations of whether to decriminalise the use of drugs we must consider the harm done to those in some sort of personal relationship with drug user.

Mill in formulating his argument believed the harm to others must be substantial to justifying curtailing someone’s liberty. For instance the harm others suffer because they don’t like drug takers taking drugs is not a substantial enough harm to count as a reason against the drug use. The question that must be answered is this. Is the harm done by drug users to those in some sort of relationship with them substantial enough to justify the continuing criminalisation of drugs? This is a difficult question to answer and I will try to address this problem by differentiating between two classes of people in a personal relationship with drug users. I will suggest provided it is possible for someone to end a relationship and with it any harm her partner’s actions inflict on her then we have no reason based on this harm to curtail his actions. Of course she may have good reasons to remonstrate, reason with or attempt to persuade him his actions are wrong, see Mill page 68. Consider for instance the situation in which the only harm a drug user’s habit does is to his partner. His partner may scold and berate him due to the harm his drug use does both to himself and her, I will assume she loves him, but she could always end the relationship and end the harm he does to her. My argument depends only on the fact that it is possible for the drug user’s partner to leave him and end the harm; it does not require that she must leave him and end the harm. Indeed in this context if she does not leave him she appears to be accepting the harm caused by her partner and this harm might be regarded to some degree as self inflicted. I have argued it is the criminalisation of drug use rather than drug use itself that damages society and that any harm done by the drug user to himself does not justify prohibiting drug use. I have further argued that any harm done to someone in a personal relationship with a drug user should not count against the decriminalisation of drugs provided she can end this relationship. However an objector whilst accepting the above might point out the domain in which my arguments are applicable is too small. She might point out that I must also consider personal relationships which the injured party cannot simply end.

The objector’s point is a sensible one and I accept it. If a drug user’s use harms people, who he is in a personal relationship with and this is a relationship which the injured parties cannot end in order to end the harm caused, does this mean we have a right to prohibit his drug use? I accept we do. My objector might now argue if I accept the above that I must also accept we should not decriminalise the use of drugs. She might point out the damage drug using parents do to their children to support her argument. I do not accept her argument. Alcohol is a drug. Drunken parents harm their children yet we do not criminalise the use of alcohol. It seems to me that, provided there is no major difference between the effects of alcohol and other drugs, we should either criminalise the use of alcohol or decriminalise the use of other drugs if our reasoning is to remain consistent. Let us assume there is no major difference between the excessive consumption of drugs and alcohol. If we were to prohibit the use of alcohol, to protect people who are in relationships which they cannot end, with abusive alcoholics we would deny many drinkers the right to drink who do no harm or if they do harm only harm themselves. At this point a utilitarian would do a calculation to maximise preferences, pleasure or some other perceived good in order to decide whether to criminalise the use of alcohol or decriminalise the use of other drugs. As I am considering theses issue by considering the idea of personal liberty such a position is not open to me. However at present drunks who abuse or neglect their children can be held accountable. They can be accused of child neglect or cruelty rather than alcohol addiction. It follows there is no need to prohibit alcohol use no need to criminalise the use of alcohol to protect the people who are in a personal relationship with an alcoholic even this is a relationship these people cannot end in order to end the harm caused. Moreover this same legislation helps protects people who are in a personal relationship with a drug user. It further follows the decriminalisation of drugs should not harm these people.

The above discussion leads me to two conclusions. Firstly if we accept Mill’s liberty principle then we should decriminalise the use of drugs. Perhaps if we do so we should also take extra special care to see vulnerable people are not abused or neglected, children in particular. The second conclusion which is more tentative and perhaps more interesting concerns the harm condition in Mill’s concept of liberty. Usually this harm condition is just taken to mean substantial harm but does not specify how substantial this harm must be to curtail liberty. I have suggested this harm condition does not apply to society in general. Mill believed it could not apply to society because he believed liberty could only benefit society. I suggested above the liberty of someone could only be restricted by the harm done to others in some sort of personal relationship with him. I then loosened this restriction. The above leads me to conclude secondly that someone’s liberty of action can only be restricted by the harm his action does to others in some sort of personal relationship with him and these others cannot end the relationship in order to end this harm.

Velleman, Guilt and Love

David Velleman defines guilt as anxiety about being in an indefensible position which means one might be cut off from social interaction. In this posting I will examine this definition. Freud says guilt is anxiety about being punished by the superego. Velleman thinks Freud is on roughly the right lines and seems to suggest that guilt might be connected to the loss of love of one’s conscience (1). I accept guilt is connected to the loss of love but will argue it is not connected to the loss of love of one’s conscience but rather to an inability to love oneself.

Velleman’s definition of guilt, as anxiety about social exclusion, means guilt is not necessarily concerned with morality. Intuitively guilt is not solely concerned with moral matters. If we accept the above it becomes difficult to differentiate between Velleman’s concepts of guilt and shame. Moreover accepting Velleman’s definition would mean excluding guilt from some situations in which we would intuitively feel the feeling of guilt would be appropriate. Because Velleman’s definition does not include these situations I will argue his definition is an inadequate one. My argument is much the same one as the one I employed in discussing his concept of shame; see Velleman and Shame 11/05/10. Let us consider someone on diet who secretly eats a lot of chocolates. Intuitively we feel such a person might feel guilty. Indeed it would seem be completely natural for us to say she has a guilty secret. However she need have no anxiety about social exclusion on account of her guilty secret. If it is accepted our dieter does indeed have cause to feel guilty then because Velleman’s definition of guilt fails to account for this his definition is an inadequate definition.

Even if our dieter is not in the danger of social exclusion due to her secret chocolate eating none the less I would suggest her position seems in some way to be indefensible. I would further suggest it might seem indefensible to her. What is indefensible in this context? Does Velleman’s suggestion that guilt is connected the loss of love of one’s conscience help us to understand what our dieter finds indefensible? In my previous posting I suggested shame might be simply seen as an unease or dissatisfaction with our sense of self as moral persons. My example of our dieter shows guilt is not simply restricted to moral matters. I believe Velleman is correct in connecting love and guilt. However I would not connect guilt to the loss of the love of one’s conscience as Velleman does. I would connect guilt to not loving oneself. As in previous postings I will accept Frankfurt’s position that love is ‘caring about’ when caring about is defined as someone persistently making herself vulnerable to losses and susceptible to benefits depending upon whether what she ‘cares about’ is diminished or enhanced (2). I will also accept Frankfurt is correct when he argues that here could not be a person whose self is of no importance to her (3). If something is important to me I must ‘care about’ it, I must love it, it follows if someone must be important to herself she must care about, love, herself to some degree. It is of course true persons need not totally care about themselves, indeed some people often talk of hating themselves, never the less I contend all persons must care about themselves to some degree. If the above is accepted guilt might be defined not as anxiety about social exclusion but rather as anxiety about being unable to truly love oneself. Such a definition might explain the secret chocolate eater’s guilt and as a result is a more complete definition than that of Velleman.

However even if we reject Velleman’s concept of guilt and accept my definition it does not follow that anxiety about being in an indefensible position with regard to society is unimportant. Such anxiety might explain why the secret chocolate eater worries about being unable to love herself. This anxiety might be explained in two ways. Firstly her anxiety may be due to the breaking some accepted social norms even if this breaking is unobservable and done in private. This anxiety might arise because she is breaking social norms which she personally accepts. Secondly her anxiety might arise as her actions are contrary to her image of herself and as a consequence of this image how she should act. This image would I suggest must be partly based on society’s expectations.

1. David Velleman, 2009, How We Get Along, Cambridge University Press, page 101)
2. Harry Frankfurt, 1988, The Importance of What We Care About, Cambridge University Press page 83.
3. Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press, page 90.

Prisoners serving Life Sentences and Assisted Suicide

In his posting on practical ethics Shlomit Harrosh connects the rights of death row inmates in certain states of the USA to choose the method of their execution and those of terminally ill patients choosing when to die, see Harrosh . Harrosh believes some personal autonomy is important even in the difficult circumstances of death row and that by choosing how to die a prisoner is to some limited degree choosing how to live as an expression of who he is and what he values as an autonomous agent.

“Like the choice of a last meal, the choice of method of execution is a final exercise in personal autonomy. Within limits, it gives prisoners the opportunity to choose the final experiences of their lives and express their values and preferences.”

Harrosh goes on to suggest that by choosing when to die terminally ill patients are making a similar choice.

“Terminally ill patients who choose voluntary euthanasia are similarly choosing how to live. The choice to hasten death is simply a means to an end: ensuring that their remaining time is lived according to their standards of a worthwhile life, expressing their values and preferences.”

Harrosh believes both of these rights have the same basis. He concludes if the right of death row inmates to choose between methods of their execution is permissible it follows that terminally ill patients have the right to choose when to die. I agree with Harrosh’s conclusion even though some might argue choosing when to die is not the same as choosing how to die.

The public at large appears to believe if some murderer, paedophile, terrorist or mass rapist attempts to commit suicide whilst in prison that no attempt should be made to prevent him doing so. In this posting I want to subject this common belief to some philosophical scrutiny. I will initially restrict my consideration to offenders who have committed terrible crimes which mean they will never be released from custody. In what follows offenders will specifically refer to those offenders who never be released from custody unless I specify otherwise. Harrosh makes a connection between the right of prisoners on death row to choose the method of their execution and the right of the terminally ill to choose when to die. I want to connect the right of terminally ill patients to choose when to die and a right of offenders to choose when to die. In what follows I will propose if terminally ill patients possess a right, to choose when to die, then so should these offenders. At the outset I must make it clear this is not an argument in support of capital punishment and that I personally do not believe in such punishment.

Do terminally ill patients have the right to choose when to die? Most people working in applied philosophy would accept this right and as a consequence I will only present a brief argument to support the right. Harrosh believes terminally ill patients have this right because they have the right to choose how to live their lives. I agree with Harrosh and would further argue these patients have the latter right because we should see such patients as the same sort of creatures as ourselves. Harry Frankfurt believes the intrinsic value of our autonomy is connected to the recognition of us by others as the kind of creature capable of determining its own destiny (1). Christine Korsgaard believes that by choosing we determine our identity (2).  If we accept that Frankfurt and Korsgaard’s views are correct then were we to deny terminally ill patients the right to choose when to die then we appear to be failing to accept these patients as the same sort of persons as ourselves. Someone might object this appearance is false and that we do see these patients as the same sort of persons as ourselves even if we deny them the right to choose when to die. He might argue we see ourselves as the sort of persons who can normally choose how to live our own lives but whom, if we became terminally ill, would have this choice restricted. I would counter argue due to our identity being so closely tied to our ability to choose if someone becomes terminally ill and his health is damaged and as a result his choices are restricted then even though he remains a person he is treated as a damaged person. I would suggest damaged health should not automatically mean a damaged person.  My objector might now argue my argument carries little weight because I have failed to adequately specify what I mean by a damaged person. I accept his argument. I suggested above our identity as persons is closely tied to our ability to choose. I would now suggest this ability to choose is not just the ability to make any choice but an ability to make an autonomous choice. The above means a damaged person might be defined as one whose capacity to make autonomous decisions has been damaged. I see no reason why most diseases or injuries must of necessity damage someone’s autonomy, diseases of or injuries to the brain might be exceptions. It follows even if disease or injury damages someone’s health that it does automatically damage him as a person and that we should continue treating him as such. Let it be accepted without any further argument that terminally ill patients do have the right to choose when to die because they have the right to choose how to live their lives. However, it is certainly not true that offenders have the same rights as the rest of us. My objector might now argue even if not all terminally ill patients are damaged persons all offenders are. I would reject such an argument as I have defined damaged persons as people whose capacity to make autonomous decisions has been damaged. I would suggest for the most part these offenders are damaged moral persons rather than damaged persons. Korsgaard would disagree with my suggestion. However I must accept some offenders are damaged persons unable to make autonomous decisions due to physiological or psychological conditions. I believe such offenders should be in secure mental health institutions such as Broadmoor rather than normal prisons. In the light of the above I will limit my discussion further to offenders in a normal prison who will never be released. I believe we should see such offenders as basically the same sort of people as ourselves, autonomous persons. Indeed history teaches us that evil is not usually perpetrated by people who are vastly different from ourselves. The Milligram Experiment further supports this point, see my previous posting. It follows even though these offenders have committed some terrible crimes they are not damaged as autonomous persons. The recognition of such offenders as undamaged autonomous persons means we should accept that they retain some choice about how to live their lives provided these choices will not harm others. For instance they may have the choice of attending religious services, which library books they choose or attending literacy classes. Should these limited choices include the right to choose to die? 

The answer to the above question depends on why we send offenders to prison. We send offenders to prison for three reasons; firstly to protect ourselves, secondly to punish the offender and lastly to rehabilitate him before he is released. We can disregard the last reason in this discussion. Prima facie if we should treat offenders as persons like ourselves then these offenders should retain all choices about how to live their lives provided these choices don’t endanger the public at large or detract from any punishment involved. Clearly giving offenders, who will never be released from prison, the right to choose when to die will not endanger us. The only question that remains to be answered is whether giving such offenders the right to choose to die detracts from their punishment? The answer to this question is not clear cut. Let it be accepted our sense of common humanity, our sense of seeing others as persons rather than monsters, does not permit us the option of cruel punishments such as simply putting an offender in a cell and metaphorically throwing away the key. It follows we must give offenders some quality of life including limited choices about how to live their lives. Provided prisoners must have some quality of life and enjoy certain limited choices it seems to me giving offenders the right to choose to die does not detract from their punishment. In the light of the above it might be concluded because the terminally ill have a right to choose when to die then so do offenders who will never be released from prison. 

I will now consider four objections to the above conclusion. This Blog is concerned with applied philosophy and someone might object it is pointless to give rights to people who will never use them. In particular it might be argued even if such offenders are the given the right to end their lives that in practice they will never avail themselves of this right. However there is some empirical evidence to show that at least some such offenders desire to die. Consider for instance consider the cases of Fred West the Gloucestershire builder who murdered 12 people and Harold Shipman who had 215 murders ascribed to him who both committed suicide in prison. Further evidence is provided by the need to place some prisoners on suicide watch.

Our objector might advance a second objection. He might point out there are a lot of mentally unstable people in prison and invariably among these people there will be some offenders who will never be released. Some of this mental instability may be due to depression. He then might argue if we give these offenders the right to choose to die rather than face life long imprisonment that some of those who exercise this option will not have made an autonomous choice due to depression. Indeed he might still further argue that if this option is made available some of offenders might feel they are being pressurised into taking it. If offenders are simply offered this choice then I believe this is a perfectly good argument. However I believe the argument loses its validity provided some safeguards are introduced. These safeguards must ensure that only offenders capable of making an autonomous decision are offered this choice. Our objector might now introduce a counter argument. He might argue these safeguards would involve counselling the offenders to ensure they can make an autonomous decision and that counselling is expensive. He might then proceed by arguing such offenders do not merit such expense and hence conclude these safeguards should not be introduced. In reply to this counter argument I would make two points. Firstly I would point out keeping people in prison for a lifetime is very expensive. If an offender who will never be released chooses to die his choice saves the taxpayer a great deal of money even if this choice includes expensive counselling. Secondly and I believe more importantly I would question whether these safeguards really need to include expensive counselling. For I would suggest all that is needed for a decision to be autonomous is that it is wholehearted and un-ambivalent. I would suggest if an offender expresses a constant un-ambivalent desire to die over a period of a few months, then his decision is an autonomous one and as such ought to be respected. Our objector might respond that my suggestion means a severally depressed offender might choose to die. In reply I would simply point out being depressed may well be the natural state of affairs for such an offender and suggest his depression does not preclude him from making an autonomous decision to die.

I have argued the reason why we should allow such offenders the right to die is based on their autonomy. I further argued that the basis of autonomy is seeing others as basically the same sort of persons as ourselves. However our objector might mount a third objection. He might argue if we allow these offenders the right to die then we are sending them a message that even at this basic level they are not the same sort of persons as ourselves. He might point out if we saw someone about to jump from a high building we would try and talk him down rather than simply pass by or tell him it’s his choice whether to jump or not. Indeed our objector might accuse us of double standards. The same objection might also be made if we allow terminally ill patients to choose when to die. I would reject his objection by arguing the difference in our attitudes is due to a difference in circumstances rather than a supposed difference in persons. An offender may be depressed and as I have suggested this depression may be both natural and normal considering his circumstances. His depression may be natural because his ongoing circumstances will not significantly change.  Someone about to jump from a building may also be depressed but his depression may not be natural and certainly need not be ongoing as his circumstances might change. These different circumstances mean the offender’s decision, subject to certain safeguards, is an autonomous one whilst the decision of the man about to jump from a high building may not be. An autonomous decision is a constant un-ambivalent decision. If we permit an offender to die we can be fairly certain his decision is an autonomous one because the prison authorities would require that he had expressed an un-ambivalent desire to die over a period of some months. The same requirement cannot be applied to someone about to commit suicide by jumping from a high building.

Our objector might now point out, offenders do not have a handy means of suicide readily available, and that if my conclusion is accepted the means of suicide would have to be approved of and brought into prison by the relevant authorities under strictly controlled conditions. I accept the objectors point. He might then use this point to raise a fourth objection to my conclusion. He might argue accepting my conclusion reintroduces capital punishment by the back door and once again accuse me of double standards due to my stated opposition to capital punishment. In reply I would reject his argument by firstly pointing out capital punishment is imposed and not simply optional. Secondly I am not proposing that the prison authorities kill these offenders even with the offender’s approval. I am proposing that the prison authorities make the means of suicide available to such offenders in controlled circumstances. These circumstances might be the much the same as those in the Dignitas clinic in Geneva. The person committing suicide in this clinic takes an anti sickness drug followed half an hour later by the overdose that kills him. In similar circumstances the offender would not have the drugs administered to him but would have them provided for him to take them himself. The fact that these drugs would be self administered would be an important additional safeguard of the offender’ autonomy, for often someone may believe he should take some course of action but when he tries to implement this action finds he cannot. For as Frankfurt points out someone’s decision only show what he intends to will and that when he attempts implement his decision he might be surprised to find out his decision does not in practice represent his will (3). In the above circumstances it would be hard to characterise the assisted suicide of an offender as capital punishment. Recently in Belgium Frank Van Den Bleeken who is serving a life sentence for rape and murder has been allowed by a court to undergo euthanasia, see bioedge . However I agree with Frankfurt that someone’s decision only show what he intends to will and in practice his decision may not always truly represent his will. For this reason whilst I believe offenders should have the right to commit suicide I would be doubtful whether this right should extend to euthanasia. 

In conclusion it appears all my imagined objector’s objections remain unconvincing. Finally I wish to consider an additional reason to that of the offender’s limited autonomy to support my position. Harrosh suggests if a prisoner on death row chooses a method of execution involving greater suffering that his choice can be a form of atonement. I would extend Harrosh’s suggestion further by suggesting if an offender chooses to die this might also be a form of atonement. In practice I don’t believe the need for atonement would be a major factor in decision making of most these offenders’ decisions to die. Rather it would be a desire to escape from life long imprisonment. None the less I believe it might be a factor in some such cases. Such atonement should be accepted not only because it is an expression of an offender’s limited autonomy but also because the acceptance of responsibility by the offender for his offences is something which may benefit the victim or victim’s relatives.

 

1. Harry Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press, page 163.
2. Christine Korsgaard,  2009, Self-Constitution, Oxford University Press.
3. Frankfurt 1988, The Importance of What We Care About, Cambridge University Press, page 84

 

Kupperman, the Milligram Experiment and Ethical Principles

Joel Kupperman points out in that western philosophy mainly centres on rules and procedures based on principles whilst eastern philosophy mainly centres on modifying the person in order to make us better people (1). He argues the focus of eastern philosophy is in many ways the more appropriate because not all normally decent people are always good people. To support his position he cites the examples of the Milligram Experiment and the Stanford Prison Experiment. He then goes on to suggest western philosophy should pay greater attention to modifying people in order to make us better individuals as well as continuing to focus on principles. His position is to some degree analogous with that of Aristotle; good or virtuous people naturally do the right thing. In this posting I want to question, even if his suggestion is accepted, whether any successful attempt at self modification can ignore ethical principles.

At the outset I must make it clear that to some degree I agree with Kupperman. It certainly seems clear to me philosophy ought to be concerned with helping us make ourselves into better persons. Furthermore it also seems that a great deal academic ethical philosophy focuses on metaethics and the principles needed to make decisions rather than the persons who make these decisions. What sort of person we are sometimes seems to be irrelevant to the way we decide. Indeed even many virtue ethicists focus more on the nature of virtues rather than the application of actual virtues. A constant theme of Kupperman’s paper is that more emphasis should be placed on self modification and less on ethical principles or metaethics. However can someone’s self modification be totally unconnected to ethical principles? I will suggest there are at least some grounds for thinking it cannot.


Kupperman argues the main reason why the Milligram Experiment is so disturbing is that we assume the participants in it were reasonably decent people in their normal lives. Briefly the Milligram experiment took place in 1961. It involved an experimenter, a teacher who was really the participant in the experiment and a learner. The learner, who was really an actor, was supposed to be learning a series of paired words. The teacher would read the first word of each pair and read four possible answers. The learner would press a button to indicate his response. If the answer was incorrect the teacher would administer what he thought to be an electric shock to the learner. The voltage was increased for each wrong answer. The shock was not real and the learner merely responded as if he had been shocked. Milligram’s Experiment showed participants were prepared to deliver large shocks in obedience to the experimenter. For a more detailed account of this experiment see The Milgram Experiment . Let it be accepted that the participants in the Milligram Experiment were indeed normally decent people. It is clear the Milligram Experiment placed these people outside their normal comfort zone. Normally people don’t make reflective decisions but rather make decisions based on habit and inclination. However in the unfamiliar context of the Milligram Experiment normal habits and inclinations appears to give the participants little basis to help them form their decisions. It might be assumed that in unfamiliar situations such as the Milligram Experiment people will think about, reflect, on their decisions. However even if this assumption is correct any reflection by the participants in the experiment did not help them to make good decisions. It might be suggested the reason for this is that these participants lacked some general ethical principles which might have formed a basis for better reflective decision making. It might then be argued, provided the above suggestion is accepted, that people need ethical principles to make good decisions in unfamiliar circumstances. It follows that anyone who attempts to modify himself in order to make himself a better person needs some ethical principles in order to remain a good person in unfamiliar circumstances. Accepting the above leads to the conclusion; any form of self modification, in order to make oneself a better person, should be partly connected to ethical principles.

Accepting the above conclusion means accepting my suggestion that the participants in the Milligram Experiment who were normally decent people behaved as they did because they lacked the ethical principles needed to make good reflective decisions in unfamiliar circumstances. Is there any evidence to support my suggestion? One place to look for evidence is to consider why some people behave well in unfamiliar and difficult circumstances. Some of this evidence appears to undermine my suggestion. For instance it appears helpers of Jewish victims of the Third Reich, who I take it to be were acting in unfamiliar circumstances, did not always help these victims because they possessed some ethical principles but rather because they felt a natural empathy for the human being standing before them. In the light of the above it is interesting to speculate as to whether the participants in the Milligram Experiment would have delivered the same shocks if they had had visual contact with the learner. The above also seems to indicate my suggestion is unsound. In the light of the above it seems reasonable to presume that anyone who attempts to modify himself in order to make himself a better person should cultivate his natural empathy rather than accept some ethical principles. He should act as Kupperman suggests. However recent research casts doubt on this presumption. Let it be accepted that women in general have a greater disposition for empathy than men. It would appear to follow if the above assumption is accepted that in any replication of the Milligram Experiment it might be assumed women would behave better than men. However when Jerry Burger of Santa Clara University replicated the Milligram Experiment this assumed gender difference did not materialise, see Replicating Milgram .

It would appear at the present time the evidence for or against my suggestion that, the participants in the Milligram Experiment might have lacked some general ethical principles which would have enabled them to make better decisions, is not clear. This is an unsatisfactory state of affairs. Perhaps some x-philosopher can devise an experiment in order to test the above suggestion. If such an experiment could be devised we might then be in a better position to say whether any successful attempt at self modification should ignore ethical principles as Kupperman appears to suggest.

1. Kupperman, 2010, Why philosophy needs to be comparative, , Philosophy 85, no 332

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Aliens and Stephen Hawking

Stephen Hawking recently stated on the Discovery channel that alien life forms probably exists somewhere in the Universe and that we should try to avoid contact with them. He suggested that if aliens come into contact with us they might be liable to act as the first Europeans acted on discovering America. He further suggested if they are anything like us they are likely to be aggressive and either exterminate us or pillage our resources. However it seems to me there is a major objection to Hawking’s suggestion. His suggestion seems to depend on the assumption that any alien morality will be much the same as that of the first colonisers of the Americas. I find such an assumption hard to accept because it seems to me, however slow and lagging behind science, there is some moral progress. As evidence of this progress I would argue modern Europeans would not behave in a similar way to their compatriots of Columbus’ time on discovering a further new world. To support this argument I need only draw attention to the fact that most Europeans in Columbus’ times were all quite happy to deal in African slaves. The idea of moral progress is dealt with by Guy Kahane at what intelligent alien life can tell us about morality. . In what follows I will assume moral progress is real. I will argue moral progress consists at least in part in the expansion of the domain of our moral concern. I will further argue any advanced aliens are likely to share this expansion.

Shaun Nichols uses investigations into child development and moral pathology to conclude that all morality includes an affective element including utilitarianism (1). In what follows I am going to assume Nichols view is correct for it seems to me to be highly improbable that any grouping consisting mainly of sociopaths could possibly form a stable or moral society. I am also going to assume the domain of creatures we feel sympathy for defines the domain of our moral concern.

I have assumed above some natural sympathy is necessary for any system of morality. Initially it seems safe to assume this empathy was limited to the people we were close to, our family for instance. With time the domain of our empathy has expanded to include our tribe, country, people who share our culture and more recently animals. How can we explain this expansion in the domain of our sympathy? Firstly it might be explained by physiological changes which increase our capacity to feel empathy. However I would be very doubtful about accepting any such explanation. The reason for my doubts being the expansion that has occurred seems to be too rapid to be explained in purely evolutionary terms. A second explanation might depend on a change in our understanding of other people or creatures. But how could a change in our understanding of others lead to a change in our capacity to feel sympathy as it might be argued we simply feel emotions? I would suggest the emotions we experience depend on both our physiological and psychological states. I would further suggest our psychological state depends to some extent on the beliefs we hold, our understanding. It seems clear sympathy is generated in response to some particular situation. I would still further suggest we naturally feel sympathy for some creature in some particular situation if we believe, we understand, the creature to be capable of experiencing the situation in much the same way we would. Accepting the above means a change in our understanding of other people or creatures might alter the domain of our sympathy. As I have assumed the domain of our sympathy defines the domain of our moral concern. It follows a change in our understanding can alter the domain of our moral concern. It further follows if we come to see some creatures, which we previously believed did not experience some situation as we do does, that there is an expansion in the domain of creatures we believe merit moral concern.

It might be doubted by some, even if they accept the domain of morality naturally expands, that we have nothing to fear from alien contact. I will now examine some of these doubts. Firstly some might question whether aliens need have a system of morality at all. Accepting the above means even if it is agreed the domain of morality naturally expands this fact is irrelevant in any of our considerations about what to do in the case of alien contact. However it seems inconceivable that any group of creatures could expand throughout the universe without some form of co-operation among themselves. Such co-operation would be a form of morality. An objector might suggest that aliens might possess only an alien form of morality. Aliens they might argue just don’t have an affective form of morality like us. I find his suggestion difficult to accept. First I find it difficult to imagine either how any group of creatures who don’t care about anything could possibly want to expand throughout the universe. And secondly as I will now argue I believe any creatures that care about each must have an affective system of morality.

I concur with Frankfurt’s belief that if some creature cares about something that it must identify itself with what it cares about and as a result make itself vulnerable to any losses connected to this caring (2). It is important to be clear Frankfurt does not connect this vulnerability to the emotions. Frankfurt connects this vulnerability directly to an absence of satisfaction with a state of affairs connected to whatever the creature identifies with. Frankfurt further holds that an absence of satisfaction with a state of affairs of whatever the creature cares about is sufficient to motivate it to act. I would agree with Frankfurt that an absence of satisfaction or dissatisfaction motivates us to act. However I, unlike Frankfurt, would argue an absence of satisfaction or dissatisfaction about the affairs of something we care about naturally leads to certain emotions, albeit faint emotions. I would suggest it is these emotions that give us reason to act. Accepting this suggestion means any advanced alien must care about something and this caring about means it must have some sort of emotions. It might be objected that the fact that an alien has emotions is not a sufficient condition for it being moral creature or for that matter even being capable of being a moral creature. After all sociopaths do have some emotions but these are not the sort of emotions needed for morality. Sociopaths live in our society, our civilization, and I am doubtful if a civilization of only sociopaths is possible. If we accept the above then any civilization, alien or not, might contain sociopaths but it can't be a civilization of sociopaths. It follows any aliens capable of expanding throughout the universe must have some form of morality  and that this morality must have an affective basis based on sympathy. 

I have argued aliens capable of travelling across space must have some sort of civilization and this means that they must feel some sort of sympathy. The fact that aliens feel sympathy by itself of course does not guarantee they will feel any sympathy towards us. Perhaps they might only feel empathy towards other aliens. I suggested above we naturally feel sympathy for some creature in some particular situation provided we believe, we understand, the creature to be capable of experiencing the situation in much the same way as we would. It appears to follow that any aliens will only naturally care about other aliens and closely related species which they believe to experience the world in much the same way as they do. I have argued above that if we come to understand others as experiencing the world as we do our domain of sympathy naturally expands. I have also argued above that aliens must “care about”, love, something as I believe persons must also do. It therefore seems probable if aliens come to understand us as at least partly experiencing the world as they do by “caring about” that the domain of their sympathy must naturally expand to include some sympathy towards us. In the light of the above it might be concluded Hawking’s suggestion that aliens are likely to be aggressive and either exterminate us or pillage our resources seems to be highly improbable.

It might be objected the way Europeans conquered and colonised the Americas is evidence that the above conclusion is unsound. It might be pointed out to me that these Europeans had a natural empathy together with a reasonable understanding of the world yet they still behaved dreadfully towards the Native Americans. I accept these Europeans had a natural sympathy but would argue their understanding of others did not encourage an expansion of the domain of their sympathy as far as ours. I have assumed moral progress in expansion of our natural sympathy is real. However, even if the expansion of natural empathy is real it is still feasible that aliens might contact us at an early stage in this expansion and behave as the European colonisers did in the Americas. Hawking’s believes the following scary scenario is possible,

“We only have to look at ourselves to see how intelligent life might develop into something we wouldn’t want to meet. I imagine they might exist in massive ships, having used up all the resources from their home planet. Such advanced aliens would perhaps become nomads, looking to conquer and colonise whatever planets they can reach.”

This scenario is indeed a theoretical possibility. The film Independence Day  depicts such a scenario. I would argue in practice such a scenario is extremely unlikely. It is hard to see how creatures, which are capable of the understanding needed to build massive ships capable of crossing the vast distances of interstellar space, failing to sufficiently understand other caring creatures to permit a natural expansion in the domain of creatures they feel some sympathy for. A more likely scenario seems to be one in which advanced aliens are at worst indifferent towards us as depicted in Arthur Clarke’s  Rendezvous with Rama  . If we accept the above then we have little reason to fear aliens even if some caution is advisable. Perhaps the real reason we feel threatened by aliens is fear feeling inferior. Lastly it seems to me many of my comments here apply equally to any emergent superintelligence.

1. Shaun Nichols, 2004, Sentimental Rules, Oxford.
2. Harry Frankfurt, 1988,The Importance of What We Care about, Cambridge University Press, page 83.

Velleman and Shame

In this posting I want to examine the concept of shame. In particular I want to consider David Velleman’s ideas on shame. Velleman defines shame as “anxiety about social disqualification constitutes the emotion of shame” (1). I will argue Velleman’s definition does not easily concur with out intuitions and suggest an alternative definition.

Let it be assumed that I am the last person left alive on earth after some plague. Let it be further assumed that because I have a stoical character I have retained my mental stability. Let it be still further assumed the rest of nature is unaffected by this plague and perhaps even benefits from it. Finally let it be assumed that it is within my powers to prevent damage the environment. Hume famously pointed out that “Tis not contrary to reason to prefer the destruction of the whole world to the scratching of my finger” (2). Let it be accepted Hume is basically correct. It follows in the above scenario, if I am not inclined to stop oil spilling into the environment perhaps because I prefer simply sitting at ease in a chair when only a little more effort would mean I could close a valve to prevent this environmental damage, then there is no rational reason for me to question my decision. It seems to me in such a scenario I might feel ashamed of my laziness and that this sense of shame would force me to question this laziness and act otherwise. However if we accept Velleman’s concept then in this situation I need have no fear of social disqualification and hence will feel no shame. Intuitively I believe in such a scenario I would feel shame. Velleman might object my above scenario is too far removed from reality for me to genuinely speculate as to whether I would feel shame. However I would point out almighty monarchs can feel shame and moreover the above considerations would be applicable in many more mundane situations. I would suggest it is possible to feel shame in a situation in which my actions would be undetectable by others. It therefore seems clear to me that fears about social disqualification offer at best only a partial explanation of shame.

I now want to argue our sense of shame is connected to our sense of self and that it is perfectly possible to feel shame without feeling any fear of social disqualification. If my argument is to be accepted then it should be possible to account for my shame predicted in the above scenario. Someone might point out to me that shame is a moral emotion and that there is a social aspect to shame. She might then argue my attempt to connect shame to a sense of self will fail because it fails to account for these social and moral aspects. I would argue that moral aspects must include both moral agents and those things, such as animals, which are of moral concern. I accept shame is a moral emotion. However I do not accept that shame cannot be connected to a sense of self if it is a moral emotion. Our sense of self is a sense of ourselves as embodied persons having certain attributes. For most of us, sociopaths excepted, this includes a sense of ourselves as moral persons. I would argue this sense of self as a moral person can only grow and flourish in a social setting. I would further argue whilst this sense of ourselves as moral persons may not be a source of great pride or self satisfaction that none the less it is important to us. We care about it. Harry Frankfurt believes caring about something means being satisfied with what we care about. He further believes this satisfaction is not some smug feeling but rather simply no active interest in bringing about a change in affairs (3). In the light of the above I would suggest shame might be simply seen as an unease or dissatisfaction with our sense of self as a moral person.

It seems to me using the above definition of shame it is possible to offer an explanation of my shame in the last man scenario outlined above. In this scenario I have previously acquired a sense of myself as a moral person in a social setting. When I become the last person alive I do not automatically lose this sense and hence still retain a disposition to feel shame even if I have no reason to fear social disqualification. In the light of the above hypothetical example I believe my definition of shame is better able to account for some of our moral intuitions than that of Velleman.

1. David Velleman 2009, How We Get Along, Cambridge University Press, page 95.
2. David Hume, 1978, A Treatise of Human Nature, Oxford, Book II, Section III, page 416, originally published 1739 – 1740).
3. Harry Frankfurt, Necessity Volition and Love, 1999, Cambridge University Press, page 103.